Provider Demographics
NPI:1003822503
Name:DANG, PHUONG DUC (MD)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:DUC
Last Name:DANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606
Mailing Address - Country:US
Mailing Address - Phone:510-465-4422
Mailing Address - Fax:510-465-1466
Practice Address - Street 1:145 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606
Practice Address - Country:US
Practice Address - Phone:510-465-4422
Practice Address - Fax:510-465-1466
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA415350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A415350Medicaid
A29401Medicare UPIN
00A415350Medicare ID - Type Unspecified